This required section states the basic purpose for this document. It is important for the Principal to understand the rights and duties of all parties before executing this document. Press [Ctrl+F1] for more information.
This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Agent. Press [Ctrl+F1] for more information.
This required section states that a Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for information.
This is a required section concerning the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if Principal is unable to do so. Press [Ctrl+F1] for more information.
In this required section the Principal states personal wishes regarding the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining procedures which artificially postpone death. Press [Ctrl+F1] for more information.
By choosing this optional section, the Principal may decide whether artificial nutrition and fluids shall or shall not be among the life- sustaining procedures provided. Press [Ctrl+F1] for more information.
This optional section gives the Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal may specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section gives the Principal the authority to set limitations on the decision making authority of the Agent. Press [Ctrl+F1] for more information.
In this required section, the Principal states whether or not the Agent has authority to make anatomical gifts for medical purposes, authorize an autopsy or direct disposition of remains. Press [Ctrl+F1] for more information.
This is an optional section which states that if the original Agent is not available, an alternate Agent will assume responsibility of the original Agent. Press [Ctrl+F1] for more information.
In this optional section, the Principal may designate a person to be his/her guardian if one needs to be appointed. Press [Ctrl+F1] for more information.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section revokes any prior Health Care Power of Attorney and gives other miscellaneous provisions regarding the health care Agent's authority. Press [Ctrl+F1] for more information.
By signing this required section, the Principal will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses. The witness statement describes limits on who may act as a witness. Press [Ctrl+F1] for more information.
This section requires the signature of a Notary Public to acknowledge that the Principal signed the document. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
Health Care POA
HCP_NC
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
!!!! !!!
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HNC01
! Disclosure Statement Section (1 of 19)
HEALTH CARE POWER OF ATTORNEY
NOTICE: THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR HEALTH CARE AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT NECESSARY TO KEEP YOU ALIVE. THIS POWER EXISTS ONLY AS TO THOSE HEALTH CARE DECISIONS FOR WHICH YOU ARE UNABLE TO GIVE INFORMED CONSENT.
THIS FORM DOES NOT IMPOSE A DUTY ON YOUR HEALTH CARE AGENT TO EXERCISE GRANTED POWERS, BUT WHEN A POWER IS EXERCISED, YOUR HEALTH CARE AGENT WILL HAVE TO USE DUE CARE TO ACT IN YOUR BEST INTERESTS AND IN ACCORDANCE WITH THIS DOCUMENT. BECAUSE THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING, YOU SHOULD DISCUSS YOUR WISHES CONCERNING LIFE-SUSTAINING PROCEDURES WITH YOUR HEALTH CARE AGENT.
It is important that this section be read in order to understand the purpose of this document, and the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions (the "Agent").
HNC02
! Designation of Health Care Agent Section (2 of 19)
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, of !, !,
! Country: !,
being of sound mind, hereby appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my health care Attorney-in-Fact (herein referred to as my "Health Care Agent") to act for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this document.
(NOTICE: Any competent person who is not engaged in providing health care to the Principal for remuneration, and who is 18 years of age or older, may act as a Health Care Agent.)
This required section states the name and address of the person appointed as Health Care Agent. The Agent will make health care decisions for the Principal if the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the Agent's name or use the P.I. Manager to select and paste a record. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so. Note the limits on who may act as Agent which appear later in this section. Press [Ctrl+F1 for more information.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country, if outside the United States.
Enter the Agent's country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours or on weekends.
Enter a phone number at which the Agent may be reached during business hours.
Enter the relationship of the Agent to the Principal.
HNC03
! Effectiveness of Appointment Section (3 of 19)
!. EFFECTIVENESS OF APPOINTMENT. (NOTICE: This Health Care Power of Attorney may be revoked by you at any time in any manner by which you are able to communicate your intent to revoke to your Health Care Agent and your attending physician.)
Absent revocation, the authority granted in this document shall become effective when and if my physician(s) determine that I lack sufficient understanding or capacity to make or communicate decisions relating to my health care and will continue in effect during my incapacity, until my death.
This determination shall be made by the following physician or physicians (you may include here a designation of your choice, including your attending physician, or any other physician. You may name one or two physicians, if desired, both of whom must make this determination before the authority granted to the health care agent becomes effective.):
Physician: !
! Physician: !
This required section states that this document shall become effective when the Principal's physician determines that the Principal is unable to make health care decisions. An optional provision allows the Principal to name the physician(s) who will make this determination. Press [Ctrl+F1] for more information.
Enter an X if the Principal desires that the determination of his/her capacity or incapacity to make decisions be made by a specific physician.
Enter the name of the specific physician or use the P.I. Manager to select and paste a record.
Enter an X if the Principal desires more than one physician to determine his/her capacity or incapacity to make decisions.
Enter the second physician's name or use the P.I. Manager to select and paste a record.
HNC04
! Authority of Agent Section (4 of 19)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Except as indicated in section 4 below, I hereby grant to my Health Care Agent named above full power and authority to make health care decisions on my behalf, including, but not limited to, the following:
A. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information.
B. To employ or discharge my health care providers.
C. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent home, or other institution.
D. To give consent for, to withdraw consent for, or to withhold consent for, x-ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, or podiatrist. This authorization specifically includes the power to consent to measures for relief of pain.
E. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.
This required section states the duties and powers the Agent on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HNC05
! Special Provisions and Limitations Section (5 of 19)
!. In exercising the authority to make health care decisions on my behalf, the authority of my Health Care Agent is subject to the following special provisions and limitations:
This required section provides the introduction for special provisions and/or personal wishes of the Principal. For example, the Principal's wishes regarding life-sustaining procedures, artificially administered nutrition, or any limits on the Agent's authority. Press [Ctrl+F1] for more information.
HNC06
! Optional Life-Sustaining Procedures Section (6 of 19)
!. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician determines that I am terminally ill, permanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Life-sustaining procedures are those forms of medical care that only serve to artificially prolong the dying process and may include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and other forms of medical treatment which sustain, restore or supplant vital bodily functions. Life-sustaining procedures do not include care necessary to provide comfort or alleviate pain.
I DESIRE THAT MY LIFE NOT BE PROLONGED BY LIFE- SUSTAINING PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY IN A COMA, SUFFER SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE.
Enter an X to include a section concerning the Principal's wishes regarding life support procedures. States may define this term differently, but generally it means procedures which artificially postpone death. Press [Ctrl+F1] for more information.
HNC07
! Optional Nutrition and Fluids Section (7 of 19)
!. STATEMENT OF DESIRES CONCERNING NUTRITION AND FLUIDS. Artificially provided nutrition or fluids provided by means of a nasogastric tube or tube into the stomach, intestines, or veins,
! shall
! shall NOT
be among the "life-sustaining procedures" that may be withheld or withdrawn.
Enter an X to include a section regarding the Agent's authority to direct the withholding or withdrawal of artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
Enter an X if artificial nutrition and fluids SHALL be among the life-sustaining procedures that may be withheld or withdrawn by the Agent's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-sustaining procedures that may be withheld or withdrawn by the Agent's authorization.
HNC08
! Optional Special Provisions Section (8 of 19)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, specify any types of treatment desired or not desired. Press [Ctrl+F1] for more information.
Use this space to include additional special provisions.
HNC09
! Optional Values and Preferences Section (9 of 19)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
HNC10
! Optional Limits on Agent's Authority Section (10 of 19)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT.
Enter an X to include a section that allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limitations on the Agent's authority to make decisions on behalf of the Principal.
HNC11
! Autopsy, Anatomical Gifts, Disposition of Remains Section (11 of 19)
!. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS.
! I authorize my Agent, to the extent permitted by law,
! do not authorize my Agent
to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
This required section states whether or not the Agent has the authority to make anatomical gifts, authorize an autopsy, and decide upon the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter an X if the Agent WILL be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter an X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains.
HNC12
! Optional Designation of Alternate Agent Section (12 of 19)
!. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order:
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Each successor Health Care Agent designated shall be vested with the same power and duties as if originally named as my Health Care Agent.
Enter an X to designate an alternate Agent. If the original Agent resigns or is unable to perform, the Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Principal's spouse as Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired. When naming an Alternate Agent, consider the availability of the Alternate Agent to confer with health care providers.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Agent to discuss medical records or information with health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Alternate Agent may be reached during non-business.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent.
HNC13
! Optional Nomination of Guardian Section (13 of 19)
!. GUARDIANSHIP PROVISION. If it becomes necessary for a court to appoint a Guardian of my person, I nominate the following person to be the Guardian of my person, to serve without bond or security.
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Enter an X to include a section that allows the Principal to nominate a person to serve as the Principal's Guardian if one is required by legal proceedings. This person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
Enter the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Principal.
Enter the Guardian's state/province or edit the information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Principal.
Enter the country or edit the information as desired.
HNC14
! Hold Harmless Section (14 of 19)
!. RELIANCE OF THIRD PARTIES ON HEALTH CARE AGENT.
A. No person who relies in good faith upon the authority of or any representations by my Health Care Agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my Health Care Agent.
B. The powers conferred on my Health Care Agent by this document may be exercised by my Health Care Agent alone, and my Health Care Agent's signature or act under the authority granted in this document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good faith by my Health Care Agent pursuant to this power of attorney are done with my consent and shall have the same validity and effect as if I were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives. The authority of my Health Care Agent pursuant to this power of attorney shall be superior to and binding upon my family, relatives, friends, and others.
This is a required section that states that the Agent and anyone who relies upon any representation by the Agent shall not be held liable. It also grants power to the Agent to make decisions on behalf of the Principal. Press [Ctrl+F1] for more information.
: X HNC15
! Miscellaneous Provisions Section (15 of 19)
!. MISCELLANEOUS PROVISIONS.
A. I revoke any prior Health Care Power of Attorney.
B. My Health Care Agent shall be entitled to sign, execute, deliver, and acknowledge any contract or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of the powers described in this document and to incur reasonable costs on my behalf incident to the exercise of these powers; provided, however, that except as shall be necessary in order to exercise the powers described in this document relating to my health care, my Health Care Agent shall not have any authority over my property or financial affairs.
C. My Health Care Agent and my Health Care Agent's estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising out of the acts or omissions of my Health Care Agent pursuant to this document, except for willful misconduct or gross negligence.
D. No act or omission of my Health Care Agent, or of any other person, institution, or facility acting in good faith in reliance on the authority of my Health Care Agent pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom criminal or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney may interpose this document as a defense.
This required section revokes all prior Health Care Powers of Attorney and provides other provisions regarding the Agent's authority. The Agent and anyone who relies on the Agent shall not be liable to the Principal or any interest of the Principal. Press [Ctrl+F1] for more information.
HNC16
! Signature Section (16 of 19)
!. SIGNATURE OF PRINCIPAL. By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my Health Care Agent.
Signed on _____ day of _______________, 19___.
________________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses and a Notary Public. If this procedure is not followed, the document may be invalid. The Principal's name was transferred from a previous section and can be modified only by returning to that section. Press [Ctrl+F1] for more information.
Enter the county or parish or edit the information as desired. The other address information was transferred from a previous section and can be modified only by returning to that section.
Enter an X to include the Principal's country in the printed document.
Enter the Principal's country or edit the information as desired.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file advance health care directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Principal's social security number or edit the information as desired.
HNC17
! Witness Signature Section (17 of 19)
[This document must be signed by the Principal in the presence of two witnesses and a Notary Public. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable.]
!. SIGNATURES OF WITNESSES (signed in the presence of a Notary Public). I hereby state that the Principal, !, being of sound mind, signed the foregoing Health Care Power of Attorney in my presence, and that I am not related to the Principal by blood or marriage, and I would not be entitled to any portion of the estate of the Principal under any existing will or codicil of the Principal or as an heir under the Intestate Succession Act, if the Principal died on this date without a will. I also state that I am not the Principal's attending physician, nor an employee of the Principal's attending physician, nor an employee of the health facility in which the Principal is a patient, nor an employee of a nursing home or any group care home where the Principal resides. I further state that I do not have any claim against the Principal.
This document requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HNC18
! Notary Section (18 of 19)
State of North Carolina
County of _________________________
CERTIFICATE
I, ________________________________________, a Notary Public for _________________________ County, North Carolina, hereby certify that ! appeared before me and swore to me and to the witnesses in my presence that this instrument is a Health Care Power of Attorney, and that he/she willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.
I further certify that !, and !, witnesses, appeared before me and swore that they witnessed ! sign the attached Health Care Power of Attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed the signing (i) they were not related within the third degree to him/her or his/her spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portion of his/her estate upon his/her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time, and (iii) they were not a physician attending him/her, nor an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and (iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument.
This the _____ day of _______________, 19___.
________________________________________
Notary Public
My commission expires: ______________________________
This section requires the signature of a Notary Public to acknowledge that the Principal signed this document. The Principal's name was transferred from a previous section and can be modified only by returning to that section. Press [Ctrl+F1] for more information.
DOM01
! Health Care Document Information Section (19 of 19)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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